Employee/Member
HRA Services

HRA Forms

These forms should be printed, filled out & signed.
Then fax or mail as per instructions on the individual forms.

• HRA Eligible Reimbursable Expenses
      * Listing of eligible reimbursable expenses for HRA accounts
  
  
• HRA Reimbursement Request
      * use when filing a manual claim
  
  
• Direct Deposit Request
      * get your reimbursements faster and easier, direct to your
        checking or savings!
  
  
• Additional Debit Card Request
      * Complete if you want a debit card for a spouse or dependent child